Copyright! Reproduction and dissemination – also partial – applicable to all media only with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden. Science & Research | Original Contribution Peer-reviewed | Manuscript received: March 23, 2018 | Revision accepted: July 23, 2018 Dietary supplements based on the ketone body β-hydroxybutyrate Market analysis and evaluation of ingredients of supplements used in the USA Tobias Fischer, Thorsten Marquardt In more recent years, there has Abstract been a continuous growth in low- The use of β-hydroxybutyrate (βHB) as a supplement to the everyday diet is a carb diets. The health merits of new development in the lifestyle supplement market. In the USA, the market is various versions of the diet with growing and the composition of the products varies greatly. The supplements different fat, protein, and carbo- are mainly postulated to be useful for providing energy, for weight loss, for in- hydrate contents are the subject of creasing athletic performance, improving mental performance, and increasing much discussion. Some versions the level of ketone bodies in the blood. Using βHB supplements in the form of are diets that closely correspond a salt has the unfavorable effect of increasing intake of sodium, potassium, cal- to a ketogenic diet and contain less cium, and magnesium. Depending on the salt composition used, it is possible than 50 g of carbohydrate per day for these supplements to cause the reference values to be exceeded by up to five (very low-carb, high-fat – VLCHF) times. Based on the currently available research, side effects cannot be ruled out. [4, 5]. In the U.S. News Diet Rank- The available research currently supports the appetite-reducing effect of ketone ings, the Atkins, Eco-Atkins and bodies. Further research is required to confirm their effectiveness with regard to Keto diets were shortlisted by 24 the other publicized areas of application, such as targeted fat loss, weight loss, experts for the categories of best and increased performance (cognitive and physiological). However, exogenous overall diet, best for weight loss, intake of ketone bodies could be advantageous in the clinical field, for example and best for rapid weight loss. The in supporting a medically necessary ketogenic diet and making it easier to follow. rating was generally better for the Atkins-based diets. In the category Keywords: β-hydroxybutyrate, ketone bodies, supplements, market analysis, ketogenic diet for rapid weight loss, the ketogenic diet (kD) even came 13th. On the other hand, the kD only achieved 39th place in the overall assess- ment [6–8]. Introduction In stark contrast to this trend, the kD is highly relevant in the field of The original founder of the low- nutritional therapy. The positive carb diet is William Banting, who effects of the traditional kD were published his “Letter on Corpu- described in epilepsy patients as lence, Addressed to the Public” in early as 1921, and it is still prac- 1865. In this letter, he criticized ticed in a similar form today [9, Citation: the increasing obesity of the pop- 10]. In addition to drug-resistant Fischer T, Marquardt T (2018) ulation. In his view, the cause was epilepsy, the classic indications for Dietary supplements based on certain foods such as bread, butter, the kD also include some rare met- the ketone body β-hydroxy- milk, potatoes, sugar, and beer. abolic diseases such as pyruvate butyrate. Market analysis and The resulting meat-, fish-, and al- dehydrogenase (PDH) deficiency evaluation of ingredients of cohol-heavy diet bears little resem- and GLUT1 deficiency. Its use in supplements used in the USA. blance to modern habits [1]. In the other metabolic diseases such as Ernahrungs Umschau 65(12): 1970s, Dr. Atkins’ book launched glycogenosis (Type III, V, and VII) 204–212 a new trend in low-carb, high-fat and complex 1 mitochondrial res- This article is available online: diets (LCHF or HFLC) [2]. The first piratory chain deficiency is also a DOI: 10.4455/eu.2018.048 two books sold 12 million copies current subject of discussion [11, and achieved cult status [3]. 12]. 204 Ernaehrungs Umschau international | 12/2018 Copyright! Reproduction and dissemination – also partial – applicable to all media only with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden. The kD is based on the formation fits described were the supporting The following article will provide of ketone bodies from acetyl-CoA, and compliance-increasing effects an overview of the ketone body which is formed by the breakdown of concomitant treatment with supplements based on βHB salts of fatty acids. In this context, ke- exogenous ketone body products available on the US market, and tone bodies means acetoacetate while on a ketogenic diet [26]. In will then weigh up the risks and (AcAc), β-hydroxybutyrate (βHB), recent years, several publications benefits. At present, no such eval- and acetone, although acetone does on ketone body salts have been uation is available – none that can not play a significant role in terms published in the wellness and life- provide an overview of the market of providing energy [13, 14]. style sector. In these publications, situation, its development, and the There are three ways to trigger the main focus is on sports ap- extent of the current “keto trend”. ketosis – meaning an increase in plications and the health benefits the level of ketone bodies in the of opting for a ketogenic diet or blood. These are fasting (hunger), choosing to supplement with ke- Methodology exercise, or a very high-fat diet tone bodies themselves [28–30]. with simultaneous reduction of It should be noted here that a ke- To compile the dataset, the largest carbohydrate intake [15–17]. In totic metabolic state was a normal online mail order company, Ama- all three cases, the glucose deficit condition for the vast majority of zon.com, was searched for prod- and the stimulation of lipolysis human history (“movement guar- ucts falling under the keywords trigger the production of an al- anteed, food intake uncertain”), “hydroxybutyrate” and “beta hy- ternative source of energy, which and it only began to disappear over droxybutyrate”. All of the products is particularly important for the the last 200 years due to increas- displayed that belonged to the cat- brain. This alternative source of ing sugar consumption, higher en- egory of foodstuffs in the broadest energy is the ketone bodies, and ergy intake and changes in lifestyle sense were viewed and listed. The especially βHB , which is the most (“movement uncertain, food intake data collection period was four abundant among them [18]. In guaranteed”) [31, 32]. The use of weeks and ended on 20 February order to significantly increase the ketone bodies as nutritional sup- 2018. In order to ensure that the level of ketone bodies in the blood plements is a new and interesting data was entered correctly, data (> 2 mmol/L), 60–90% of daily development on the global market. entry was done by two people. In energy intake (E%; Low Glycemic the case of several pack sizes, the Index Treatment [LGIT] vs. clas- Increasing general and scientific medium-sized pack was listed. Dif- sic kD 4:1) need to come from fat interest in the kD has led to new ferent flavors or formulations with [19]. Generally, it is assumed that areas of application being opened different ingredients (e.g. with or in adults, a carbohydrate intake of up. In addition to the classic appli- without caffeine) were entered into over 50 g per day will not produce cations of weight loss and perfor- the dataset as separate products. ketosis, or will only do so to a very mance enhancement, there is also The following information was limited extent [20]. The fact that much discussion about positive ef- gathered and used for the evalu- this diet is so different from a nor- fects when used in cancer or neu- ation: the product name, manu- mal balanced diet leads to problems rodegenerative diseases (dementia, facturer, quantity, price, serving with compliance, which in turn Alzheimer’s, etc.) [33]. In terms of size, ingredients (macro and mi- leads to treatment discontinuation trend diets using ketone bodies or cronutrients, βHB), additives, other [21, 22]. the kD, the appetite-reducing effect ingredients (sweeteners, plant ex- is one of the most commonly cited tracts, etc.), consumer ratings and Back in the 1980s, exogenous in- advantages [34]. the main advertising statements. take of ketone bodies had already For the statistical calculation, de- caught the attention of the field The kD appears to have great mar- scriptive statistical methods (mean of sports medicine [23, 24]. Later ket potential. At present, there is value, median, standard deviation) on, possible medical applications no data on the size of the market were carried out using the pro- started to be discussed and com- for the kD and related products. grams Microsoft Excel 2016 and passionate use treatments were Alongside the supplements men- IBM SPSS Statistics 24. For nomi- carried out using sodium βHB in tioned above, during the kD, it is nal data, such as advertising state- various rare metabolic diseases, also possible to self-track by meas- ments, the number of them was such as Multiple Acyl-CoA-De- uring general vital parameters, determined and compared with the hydrogenase Deficiency (MADD), blood values (βHB, glucose), and total quantity of products. PDH deficiency, and hyperinsu- the concentration of acetone in the linism [25–27]. Among the bene- exhaled air [35, 36]. Ernaehrungs Umschau international | 12/2018 205 Copyright! Reproduction and dissemination – also partial – applicable to all media only with written permission of Umschau Zeitschriftenverlag GmbH, Wiesbaden. Science & Research | Original Contribution N = 86 Price ($) Price per portion ($) Pack size (g) Portion size (g) Portions per day Mean 50.24 2.99 316.7 17.3 2.8 Median 49.95 2.80 240.0 15.0 3.0 SD 23.12 1.52 154.8 7.2 0.4 Min.–Max.